INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 18, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Inc. Winner Co-Occurring Women and Children Program was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Three personnel records were reviewed during the renewal inspection on May 18, 2016. The facility failed to document the completion of HIV/AIDS training in personnel record # 3.
Employee # 3 was hired as a counselor on 12/26/14. The required HIV/AIDS training was due to be completed no later than 12/26/15. The facility failed to document the completion of HIV/AIDS training.
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Plan of Correction
Program Director will review trainings monthly for the next 12 months to ensure compliance with training requirements for all employees. This will be added to monthly CQI reporting.
Employee # 3 was completed HIV/AIDS training on June 15, 2016.
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705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
The fire drill logs were reviewed on May 18, 2016. The facility failed to provide documentation to verify that unannounced fire drills had been conducted at least once per month for the months of June 2015, July 2015, and August 2015.
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Plan of Correction
House manager Supervisor will schedule fire drills monthly and ensure 1 unannounced fire drill each month.
Program Director will review schedule and sign off on completed drills at months end. |
709.28(d) LICENSURE Confidentiality
709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Seven client records were reviewed during the renewal inspection on May 18, 2016. The facility failed to document that the client was offered a copy of the consent to release information in client records # 1, 2, and 3.
Client # 1 was admitted into treatment on 2/23/16 and was still active at the time of the inspection. A consent to release information, signed and dated on 4/11/16, failed to document whether or not the client was offered a copy.
Client # 2 was admitted into treatment on 2/1/16 and was still active at the time of the inspection. A consent to release information, signed and dated on 2/1/16, failed to document whether or not the client was offered a copy.
Client # 3 was admitted into treatment on 4/28/16 and was still active at the time of the inspection. A consent to release information, signed and dated on 4/28/16, failed to document whether or not the client was offered a copy.
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Plan of Correction
Program Director will review charts monthly for completed release of information for the next twelve months.
Training will be done with staff for appropriate completion of forms by 7/8/2016.
For clients still in programming, the primary counselors will sit with each client and complete all requirements of the form. Each client will be asked if they want a copy of the release.
If copies of the releases are requested, the primary counselor will do it immediately before the client leaves the office. This will be done by 7/8/2016. |
709.53(a) LICENSURE Complete Client Record
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
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Observations
Seven client records were reviewed on May 18, 2016. The facility failed to ensure that a complete record was documented in client records # 1, 4, 5, 6, and 7.
Client # 1 was admitted into treatment on 2/23/16 and was still active at the time of the inspection. Progress notes in the client's record indicated that the client attended individual counseling sessions on 3/16/16 and 3/25/16, and a group counseling session on 4/21/16. These counseling sessions were not on the client's record of service. Additionally, the client's record of service indicated that the client attended a group counseling session on 4/25/16. However, a progress note documented in the client's record, for this group counseling session, indicated that the client did not attend the group counseling session.
Client # 4 was admitted into treatment on 10/5/15 and was discharged on 2/26/16. A progress note in the client's record indicated that the client attended an individual counseling session on 1/22/16. This counseling session was not documented on the client's record of service. Additionally, the client's record of service indicated that the client attended individual counseling sessions on the following dates: 12/2/15, 12/10/15, 1/12/16, 1/13/16, and 1/23/16. Progress notes for these counseling sessions were not documented in the client's record.
Client # 5 was admitted into treatment on 8/31/15 and was discharged on 10/6/15. A record of service was not documented in the client's record. Progress notes in the client's record indicated that the client attended individual counseling sessions on the following dates: 9/3/15, 9/10/15, 9/17/15, and 10/5/15. Additionally, progress notes in the record indicated that the client attended group counseling sessions on the following dates: 9/16/15, 9/23/15, and 9/30/15.
Client # 6 was admitted into treatment on 10/26/15 and was discharged on 2/17/16. Progress notes in the client's record indicated that the client attended individual counseling sessions on 11/13/15 and 11/19/15. These counseling sessions were not documented on the client's record of service. A record of service for the months of December 2015, January 2016, and February 2016 was not documented in the client's record. Documentation in the client's record indicated that the client attended group counseling sessions on the following dates: 12/10/15, 12/17/15, 12/22/15, 1/21/15, and 1/28/15. These counseling sessions were only documented on "Activity Summary Sheet" forms. A record of service and progress notes for these counseling sessions were not documented in the client's record.
Client # 7 was admitted into treatment on 12/9/15 and was discharged on 3/11/16. A record of service was not documented in the client's record. Progress notes in the client's record indicated that the client attended individual counseling sessions on the following dates: 12/21/15, 12/31/15, 1/4/16, 1/18/16, 1/25/16, 1/26/16, 2/9/16, 2/19/16, and 3/3/16. Additionally, progress notes in the client's record indicated that the client attended group counseling sessions on 1/27/16 and 2/3/16.
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Plan of Correction
Each client chart will be reviewed by the Program Director monthly for CQI and chart completeness.
Charts are currently being bought up to date for completeness.
Clinical supervisions will be held monthly specific to chart review and chart compliance. |